Chronic rhinosinusitis with nasal polyps and allergic rhinitis as different multimorbid treatable traits in asthma

Abstract

Background: Respiratory multimorbidities are linked to asthma, such as allergic rhinitis (AR) with early allergic asthma and chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP) with late nonallergic asthma.

Objective: Our aim was to investigate the association of asthma severity and control with specific upper airway phenotypes.

Method: Patients with asthma were prospectively recruited from 23 pulmonology and ear, nose, and throat clinics. Asthma severity and control, as well as upper airway comorbidities (AR and non-AR [NAR], CRSwNP, and CRS without nasal polyps [CRSsNP]) were assessed according to international consensus guidelines definitions.

Results: A total of 492 asthmatic patients were included. Half of the asthmatic patients (49.6%) had associated rhinitis (37.0% had AR and 12.6% had NAR) and 36.2% had CRS (16.7% had CRSsNP and 19.5% had CRSwNP), whereas 14.2% had no sinonasal symptoms. Most cases of AR (78%) and NAR (84%) were present in patients with mild-to-moderate asthma, whereas CRSwNP was more frequent in patients with severe asthma (35% [P < .001]), mainly nonatopic asthma (44% [P < .001]). Patients with severe asthma with CRSwNP had worse asthma control, which was correlated (r = 0.249 [P = .034]) with sinus occupancy. Multiple logistic regression analysis showed that late-onset asthma, intolerance of aspirin and/or nonsteroidal anti-inflammatory drugs, and CRSwNP were independently associated with severe asthma.

Conclusion: Severe asthma is associated with CRSwNP, with sinus occupancy affecting asthma control. This study has identified 2 main different upper airway treatable traits, AR and CRSwNP, which need further evaluation to improve management and control of patients with asthma.

Keywords: Asthma; allergic rhinitis; asthma control; asthma severity; chronic rhinosinusitis with nasal polyps; united airway disease.

Fig 1

Frequency of sinonasal phenotypes in asthma (N = 492). Percentage of patients using nasal symptoms (86%) (A); using ARIA and European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) guideline definitions (50% had rhinitis whereas 36% had CRS) (B); and using allergy testing, nasal endoscopy, and sinus CT scan (14.2% were without sinonasal disease, 13% had NAR, 37% had AR, 16% had CRSsNP, and 20% had CRSwNP (C).

Fig 2

Frequency (A) and association (B) of sinonasal diseases according to asthma severity. CRSwNP shows an increased frequency of (35.1% [P < .001]) and association with (OR = 3.37 [95% CI = 1.69-6.78] [P < .001]) severe persistent asthma. The frequency and association of AR and NAR and CRSsNP are similar in all asthma severity groups. Frequency is expressed as a percentage, and association is expressed as an OR (95% CI).

Fig 3

Sinonasal CT LMS scores in patients with CRSwNP and CRSsNP according to asthma severity. A, Patients with severe asthma shows higher LMS scores than patients with nonsevere asthma do (P = .014). B, LMS scores in patients with CRSwNP (r = –0.249; P = .034), but not in patients with CRSsNP (r = 0.091; P = .567), were negatively correlated with Asthma Control Test (ACT) score. The Pearson correlation coefficient (r) was used for the correlation. Quantitative variables are expressed as medians and IQRs.

Fig 4

Age, sex, age of asthma onset, prevalence of nasal polyps, AIA, and atopy in patients with severe asthma and patients with mild-to-moderate persistent asthma. ∗∗P < .01; ∗∗∗P < .001.

Fig E1

Venn diagram for sinonasal phenotypes in asthma (N = 492). According to ARIA and European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) guideline definitions. The diagram includes patients with rhinitis (n = 244 [50%]), patients with both AR (n = 182 [37%]) and NAR (n = 62 [12.6%]), patients with CRS (36%), patients with both CRSsNP (n = 82 [16.7%]) and CRSwNP (n = 96 [19.5%]), and a few patients without sinonasal disease (n = 70 [14.3%]).